Project Summary Physician-scientists (MD-PhDs and other MDs) are uniquely positioned to address national healthcare challenges by combining their clinical perspectives with scientific insight to provide a scientifically rigorous approach to patient care. A diverse biomedical-research workforce is expected to yield a broader spectrum of novel research questions for studying disease risk, pathogenesis and outcomes, response to treatments, and ways to reduce health disparities. However, the physician-scientist workforce remains relatively lacking in racial/ethnic and gender diversity compared to U.S. medical-school graduates. The objective of this project (a second competitive renewal of R01 GM085350) is to identify barriers to and facilitators of research grant applications, resubmissions, and awards among underrepresented groups in the federally funded biomedical- research workforce, including racial/ethnic minority groups (e.g., Black, American Indian/Alaska Native, and Hispanic) and women. Using a database for an entire pre-applicant population of the 1993-2000 national cohort of 129,867 U.S. medical-school matriculants, we address six Aims, examining outcomes in relation to demographic, institutional, research-related, educational/academic, and professional-development variables. Aims 1-4 will identify variables associated with:1) MD-PhD-degree program enrollees' application for and receipt of F30 and F31 pre-doctoral fellowships; 2) medical graduates' application for F32, mentored-K (K01/K08/K23), and R01 grants; 3) applicants' receipt of F32, mentored-K and R01 awards; and 4) re- submission of unfunded applications and subsequent awards. For racial/ethnic and gender disparities in grant application, resubmission, and award outcomes identified in Aims 2-4, Aim 5 will identify causal mechanisms between each of race/ethnicity and gender and each of the outcomes using causal mediation analysis. Aim 6 will identify variables associated with academic-medicine faculty promotion to a senior rank (associate professor or full professor), attrition without promotion, and mean time to event. We will create a unique, longitudinal database of de-identified data for individuals in this national cohort, with new data from the Association of American Medical Colleges, American Medical Association, and the National Institutes of Health Information for Management, Planning, Analysis, and Coordination (IMPAC) II grants database, which has never before been linked to data for an entire national pre-applicant population. We use multivariable logistic regression models to identify variables associated with grant outcomes, and causal mediation analysis to identify causal mechanisms between race/ethnicity and each grant outcome. Subdistribution hazard ratios will measure effects of variables on the instantaneous probability of two competing events, promotion and attrition; subdistribution hazard function is directly linked to the probabilities of these competing events over time. The new knowledge created from this project will inform the design of interventions to promote greater racial/ethnic and gender diversity of the federally funded, physician-scientist research workforce.